Umeå University
This is a published version of a paper published in BMC Medical Education.
Citation for the published paper:
Diderichsen, S., Johansson, E., Verdonk, P., Lagro-Janssen, T., Hamberg, K. (2013)
"Few gender differences in specialty preferences and motivational factors: a cross- sectional Swedish study on last-year medical students"
BMC Medical Education, 13: 39
URL: http://dx.doi.org/10.1186/1472-6920-13-39
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R E S E A R C H A R T I C L E Open Access
Few gender differences in specialty preferences and motivational factors: a cross-sectional
Swedish study on last-year medical students
Saima Diderichsen 1* , Eva E Johansson 1 , Petra Verdonk 2 , Toine Lagro-Janssen 3 and Katarina Hamberg 1
Abstract
Background: Today, women constitute about half of medical students in several Western societies, yet women physicians are still underrepresented in surgical specialties and clustered in other branches of medicine. Gender segregation in specialty preference has been found already in medical school. It is important to study the career preferences of our future physicians, as they will influence the maintenance of an adequate supply of physicians in all specialties and the future provision of health care. American and British studies dominate the area of gender and medical careers whereas Swedish studies on medical students ’ reasons for specialty preference are scarce. The aim of this study is to investigate and compare Swedish male and female medical students ’ specialty preferences and the motives behind them.
Methods: Between 2006 and 2009, all last-year medical students at Umea University, Sweden (N = 421), were invited to answer a questionnaire about their future career and family plans. They were asked about their specialty preference and how they rated the impact that the motivational factors had for their choice. The response rate was 89% (N = 372); 58% were women (N = 215) and 42% were men (N = 157). Logistic regression was used to evaluate the independent impact of each motivational factor for specialty preference.
Results: On the whole, male and female last-year students opted for similar specialties. Men and women had an almost identical ranking order of the motivational factors. When analyzed separately, male and female students showed both similarities and differences in the motivational factors that were associated with their specialty preference. A majority of the women and a good third of the men intended to work part-time. The motivational factor combining work with family correlated with number of working hours for women, but not for men.
Conclusions: The gender similarities in the medical students ’ specialty preferences are striking and contrast with research from other Western countries where male and female students show more differences in career aspirations. These similarities should be seized by the health care system in order to counteract the horizontal gender segregation in the physician workforce of today.
Background
In the U.S. and in Europe, the number of women in medical schools started to increase in the 1970s [1,2].
The careers of these female physicians were expected to follow a linear development in all fields and levels of medicine. In the late 1990s, the time-lag phenomenon no longer could explain women’s lack of career advance- ment in male-dominated specialties such as surgery, and
research on gender and medical careers started to grow [2]. Today, when women constitute about half of med- ical students in several Western societies [3-6], statistics still show that women physicians are underrepresented in high-status specialties like surgery and clustered in specialties characterized by relatively low earnings or prestige [7-9]. Gender segregation in specialty preference has been found already in medical school [10-12] and previous studies have not been able to show any changes in this remarkably stable and almost universal pattern [1,13,14].
* Correspondence: saima.diderichsen@gmail.com
1
Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå 901 85, Sweden
Full list of author information is available at the end of the article
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The motives behind specialty preference have been studied, both on an individual level and on a structural level. On an individual level it has been revealed that fe- male students consider work- and time-related aspects and patient orientation whereas their male peers con- sider technical challenge, salary, career prospects and prestige [11,15-18]. It has also been shown that medical students and young physicians of both genders value lifestyle factors and consider balance between work and private life [19-22]. On a more structural level, lack of social support and a scarcity of role models have been shown to affect men and women’s specialty preference [1,16,23]. Moreover, the scarcity of female physicians in surgery has been found to be a result of a masculine ex- clusionary practice and a consequence of women’s choices being made in relation to their immediate or expected family duties [24].
That women are expected to and generally do take more responsibility for domestic work has been a com- mon explanation for gender differences in men’s and women’s individual career choices. There is a national context that needs to be taken into consideration here, as career choices are always made within a frame of ref- erence, composed of the possibilities and limitations that can be found in a certain context [25]. American and British studies dominate the area of gender and medical careers [2]. However, their social policies differ from that in Sweden, where paid parental leave and subsidized childcare encourage women and men to share paid and unpaid work equally [26]. Social policies of this type affect individuals’ behavior: how they choose their careers and organize their private lives [25]. Therefore, Sweden is a good place to study male and female med- ical students’ career preferences, as the norms of gender equality are relatively strong, especially among the highly educated [26,27]. To our knowledge, Swedish studies on medical students’ reasons for specialty preference are scarce. Medical students’ career preferences per se are important to study, as their choices will influence the maintenance of an adequate physician supply and the future provision of health care. Therefore, the objective of our study is to compare specialty preferences and motivational factors of male and female graduating med- ical students. We will investigate associations between motivational factors and specialty preference in order to determine reasons contributing to specialty choices.
Method Study population
This cross-sectional study is part of the project Gender Challenges in Medical Education [12]. Between 2006 and 2009, all classes of last-year medical students at Umea University in Sweden (N = 421) were asked to complete a confidential questionnaire (58% women, 42%
men). The students could stay on after an ordinary lecture and fill out the survey. The response rate was 89% (N = 372). Among the respondents, 58% (N = 215) were women and 42% (N = 157) were men.
The questionnaire
The questionnaire included socio-demographic ques- tions such as students’ sex, age and family status. The students were asked to choose one out of seven special- ties or the options something else and I don’t know.
Under something else the students added eight more. In order to create larger categories these 15 specialties were merged into three groups: Surgical specialties (general surgery, otolaryngology, ophthalmology, anesthesiology and gynecology), non-surgical specialties (internal me- dicine, pediatrics, psychiatry, neurology, venereology, infectious diseases, radiology, oncology and laboratory specialties) and family medicine. Surgical specialties and family medicine were separated as they differ both in content and in number of hours on call. The non-surgical group was relatively diverse as we merged specialties such as pediatrics, internal medicine and laboratory medicine into the same group. Students who opted for two or more specialties from different specialty groups were merged with students who chose “I don’t know”. This group was named “uncertain”. There was no distinct pattern in the group that opted for two or more specialties. The combi- nations ranged from two to six different specialties and there was no combination that occurred more than twice.
Based on literature, ten motivational factors that might contribute to the students’ preference for specialties were defined [28,29]. The students were asked to rate (Likert scale 1 to 5) how important these factors were when they were to choose a specialty. Three of the motivational factors were deleted from the analysis. The two factors: in line with my former student experience and in line with my former work experience were taken away since they had no association with the specialty preferences. The third factor, attractive working hours, was excluded, as it correlated strongly with the factor combining work with family in both women and men.
There was also a specific question where the students were asked to state ideal working hours, and that ques- tion was used in a separate analysis.
Statistical analyses
Binary logistic regression was applied to investigate the associations between motivational factors and specialty preference. In this regression analysis men and women were analyzed separately. To assess gender differences in these links between motivational factors and specialty preference, gender was combined with each motivational factor as interaction term. Also, a linear regression ana- lysis was conducted in order to reveal any correlation
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between preferred number of working hours and the rating of the motivational factor combining work with family.
Analysis was made in SPSS 20.0 for Mac and the Pearson chi-square test was used to determine the significance of specialty preferences and motivational factors. To reveal any significant gender differences in the rating of the motivational factor we used the non-parametric Mann–
Whitney U test. The significance was set at p < .05.
The Regional Ethical Review Board at Umea University has approved this study.
Results
Socio-demographics
About half of both male and female students lived together with a partner (see Table 1). A higher propor- tion of men than women had children, but this was not a significant difference. A vast majority of the students had highly educated (university education) parents who worked full-time (40 hours or more per week). More mothers than fathers worked part-time, reflecting gender differences in the general population. Many of the students’ parents were retired, which partly explains the
high proportion in the variable other under working status father and working status mother.
Gender and career preferences
The most frequently preferred specialties among both men and women were surgery, family medicine and internal medicine (Table 2). Gynecology and pediatrics were also rather common, especially among women.
Almost a third of the students were uncertain of their specialty preference. This might seem high, but gradu- ated medical students in Sweden still have at least one and a half years of internship before they can go into residency training. A total of four students (three men and one woman) were not included in this analysis, as they had chosen “other” without specifying which other specialty. There was only one statistically significant gender difference; more women than men chose gynecology.
A large proportion of both men and women preferred part-time practice (see Table 2). It was however signifi- cantly more common among the women; a majority of the female students (54%) compared with a good third their male peers (36%) intended to work less than 40 hours per week. The highest proportion of students
Table 1 Socio-demographics of participating male and female students
Category Variable Women Men p
(N = 216) (N = 157) Mean (SD) Mean (SD)
Age 27.3 (3.2) 27.7 (3.2) NS
% (N) % (N)
Civil status Not
cohabiting
50 (107) 46 (73) NS
Cohabiting 50 (109) 54 (84)
Children No 89 (192) 83 (131) NS
Yes 11 (24) 17 (26)
Highest education mother
Higher 73 (157) 78 (121) NS
Intermediate 20 (43) 17 (27)
Primary 7 (14) 5 (7)
Highest education father
Higher 64 (137) 75 (116) .042
Intermediate 22 (47) 18 (27)
Primary 14 (30) 7 (11)
Working status mother Full-time 60 (129) 71 (112) NS Part-time 18 (38) 14 (22)
Other 22 (48) 15 (23)
Working status father Full-time 69 (148) 68 (106) NS
Part-time 5 (10) 6 (10)
Other 27 (58) 26 (41)
Note: Significance level for gender differences was set at p < .05. SD = Standard deviation. NS = not significant. p < .05 in bold.
Table 2 Male and female students ’ career preferences
Variable Category Women Men p
N = 215 N = 157
% (N) % (N)
Specialty preference Surgical specialties
27 (58) 29 (44) NS
Surgery 17 (36) 23 (36) NS
Gynecology 8 (17) 3 (4) .028
Anesthesiology 2 (5) 3 (4) NS Non-surgical
specialties
22 (48) 24 (37) NS
Internal medicine 8 (17) 9 (14) NS
Pediatrics 7 (15) 4 (6) NS
Psychiatry
a3 (6) 3 (5) NS
Neurology 2 (4) 3 (5) NS
Others 3 (6) 5 (7) NS
Family medicine 18 (38) 17 (26) NS
Not sure 32 (68) 30 (47) NS
Preferred working hours (hours per week)
More than full-time (>40)
2 (5) 10 (15) .001
Full-time (40) 40 (85) 51 (80) Slightly less than
full-time (31 –39) 23 (50) 12 (19) 75% and less ( ≤30) 31 (66) 24 (37)
Other 4 (9) 4 (6)
Note: Significance level for gender differences was set at p < .05. NS = not significant. p < .05 in bold.
aPsychiatry includes child and
adolescent psychiatry.
(29%) who preferred part-time were those who opted for family medicine (not shown in table). Looking at those who preferred family medicine, 80% of the women and 68% of the men intended to work part-time.
Motivational factors
Men and women differed somewhat in the importance they attached to the seven motivational factors (see Table 3). Women rated interesting content, a lot of patient contact and combining work with family significantly higher than men. Still, when the motivational factors were listed from highest to lowest rating, men and women had an almost identical ranking order. The only difference in rank was that patient contact was rated higher than tech- nical skills among women, whereas the opposite was the case for the men.
A total of 120 participants added a motivational factor of their own. About a third of these described a good working climate and having nice colleagues as important when choosing specialty (not shown in table). Other motives were: having possibilities to develop, being able to choose where to live and having variation in duties.
The possibility to choose where to live was primarily mentioned by those preferring family medicine.
Motivational factors associated with specialty preference Both gender similarities and differences were disclosed in the associations between motivational factors and specialty preference (see Table 4). For both women and men, a high rating for technical skills and a low rating for combining work with family were associated with a surgical preference. It was only among women that good salary was positively associated with preferring surgical specialties. Women and men who opted for non-surgical specialties such as internal medicine or pediatrics gene- rally rated research opportunities high. Among women, a high rating of interesting content was linked to a non-
surgical specialty. For both men and women, valuing pa- tient contact had a positive association with a preference for family medicine. Women who preferred family medi- cine generally rated combining work with family and good salary high and rated interesting content, technical skills and career prospects low. Male and female students who were undecided generally valued being able to com- bine work with family. Women who were uncertain gen- erally rated patient contact low.
When gender as an interaction term was studied in the association between motivational factors and spe- cialty preferences, two significant differences were found.
First, a high rating of good salary had a stronger positive association with the women’s preference for surgery (OR 1.9) than it had for the men’s (OR 0.8). Second, women’s preference for family medicine had a stronger negative affiliation with career prospects (OR 0.4) than it had for men (OR 0.8).
The linear regression analysis investigated any associ- ation between ideal working hours and combining work with family (not in table) and showed that for women – not for men – the number of working hours correlated with how they rated combining work with family (for women p = .000 and for men p = .389). Opting for part- time meant a high rating of combining work with family and conversely: a low rating meant full-time or more.
Discussion
This study aimed to investigate and compare male and female students’ specialty preferences and the motives behind them. Our results showed almost no gender dif- ferences in the specialties the students opted for. More- over, men and women had an almost identical ranking order of the motivational factors. Male and female stu- dents did differ in the motivational factors that were as- sociated with their specialty preference. However, just two statistically significant gender differences were re- vealed when using gender as an interaction term. A ma- jority of the women, compared with a good third of the men, intended to work part-time. It was only for women that the ideal number of working hours was linked to the importance they attached to having time for family.
Gender and career preferences
In contrast to earlier studies on medical students, we did not find any significant difference between men and women in their preference for surgery [11,12,21]. Our re- sults were supported by a study conducted in all Swedish medical schools where no differences in specialty prefer- ence between male and female last-term medical students were revealed [30]. Also, earlier research has shown a trend where the proportions of female medical students who prefer male-dominated specialties are increasing [19,21]. Still, this equal distribution between men and Table 3 Rating (Likert scale 1 –5) of motivational factors
for specialty preference
Motivational factors Women Men p
N = 215 N = 157
Mean (SD) Mean (SD)
Interesting content 4.7 (0.5) 4.5 (0.6) .004
A lot of direct patient contact 4.1 (0.9) 3.9 (0.9) .013 In line with technical skills 4.1 (1.1) 4.0 (1.0) NS Combining work with family 3.9 (1.1) 3.6 (1.1) .020
Career prospects 3.3 (1.0) 3.4 (1.0) NS
Good salary 3.1 (0.9) 3.2 (1.1) NS
Research opportunities 2.8 (1.2) 2.9 (1.2) NS
Note: Significant gender differences were measured using a non-parametric test (Mann–Whitney U test); significance level was set at p < .05. NS = not significant. p < .05 in bold.
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women clashes with the horizontal gender segregation in medical specialties seen in Sweden and other Western societies [7,9]. This could either mean that women will continue to increase in male-dominated specialties or that the problem lies after graduation. In a Norwegian study, female and male residents were equally distributed when starting their first specialty training, but fewer women than men finished their specialty training in surgery [31].
Hence, there seem to be barriers such as masculine homo- sociality, with men preferring men (and excluding women), lack of social support and a scarcity of role models that might only become evident during residency.
That more women than men opted for gynecology and pediatrics could be explained by female physicians being numerous in these specialties over the past decades and hence there are more same sex role models. Also, the students were on gynecological and pediatric training at the time of the questionnaire.
Both male and female students seemed to value patient contact and combining work with family more than career prospects and good salary. This could be explained in part by the fact that a majority of the students lived with a partner and by the age of twenty- seven, family-life might seem close in time. Our results are in concert with another Swedish study, where male and female physicians mainly showed similarities in their specialty motives; interesting content, patient contact and a good working environment were important for
both women and men [32]. Yet, our results contrast with previous studies from other countries where mainly women considered work and time-related aspects and patient orientation whereas men considered technical challenge, salary, career prospects and prestige when choosing specialty [11,15,16,18]. Both Norwegian and Swedish students [19,30] compared with students from, for example, the Netherlands and the U.S. distribute themselves more equally in their specialty preferences and also in how they rate the motives for them [10,12].
Perhaps this could be explained by different national contexts. The fact that both Sweden and Norway have more far-reaching gender equality legislation compared with countries like the U.S. and the Netherlands [26], is probably reflected in the values among the medical students. Thus, strong norms of gender equality as a frame of reference might affect the students’ career pre- ferences and their motives for them.
In a study on Swedish residents, men and women in male-dominated specialties (such as surgery) attached similar importance to combining work with family, whereas those in specialties with more women differed in their priorities [32]. The same pattern can be seen in our results as well: men and women who opted for surgical specialties had the same low rating in combining work with family, whereas among those who preferred family medicine it was only women – not men – who considered time for family to be important. Those who opted for Table 4 Motivational factors associated with specialty preference
Women Men
N = 214 N = 154
OR p OR p
Surgical specialties Combining work with family 0.4 (0.3 –0.6) .000 0.4 (0.3 –0.7) .000
Good salary
a1.9 (1.2 –3.0) .004 0.8 (0.5 –1.3) NS
In line with technical skills 1.4 (1.0 –1.9) .034 1.9 (1.2 –3.0) .011
Lots of direct patient contact 0.9 (0.6 –1.3) NS 0.6 (0.4 –0.9) .018
Non-surgical specialties Research opportunities 1.4 (1.0 –1.9) .023 1.9 (1.3 –2.9) .001
Good salary 0.4 (0.2 –0.6) .000 0.8 (0.5 –1.3) NS
Interesting content 2.4 (1.0 –5.5) .048 1.7 (0.8 –3.9) NS
Family medicine Lots of direct patient contact 3.7 (1.8 –7.9) .001 2.9 (1.4 –6.0) .005
Career prospects
a0.4 (0.2 –0.7) .002 0.8 (0.4 –1.5) NS
Combining work with family 2.3 (1.3 –4.2) .004 1.6 (0.9 –2.9) NS
Good salary 1.9 (1.1 –3.3) .018 1.7 (0.9 –3.2) NS
Interesting content 0.4 (0.2 –0.9) .024 0.8 (0.4 –1.9) NS
In line with technical skills 0.6 (0.4 –1.0) .045 0.7 (0.5 –1.2) NS
Research opportunities 0.8 (0.6 –1.3) NS 0.6 (0.4 –1.0) .031
Uncertain Combining work with family 2.1 (1.5 –3.1) .000 1.8 (1.2 –2.7) .005
Lots of direct patient contact 0.6 (0.4 –0.8) .003 1.0 (0.7 –1.5) NS
Note: Specialty preference (outcome) = modeling the probability of choosing it (not choosing it = ref.). Mediators = motivational factors (probability of choosing a
specialty preference). OR = odds ratio (95% CI = confidence interval). Significance was set at p < .05. NS = not significant. p < .05 in bold.
aSignificant interaction
term with gender in separate analyses on each motivational factor.
family medicine also chose part-time to a higher degree.
It seems that women consider family medicine a family friendly specialty. This was consistent with women’s part- time preference being linked to having time for family.
Thus, for women family medicine and part-time practice seem to be a strategy to combine work with family duties.
For men, the choice of part-time and family medicine is about something else, which remains unmeasured.
Being uncertain and preferring non-surgical specialties were associated with relatively few motivational factors.
This could be because these two groups were the most diverse. In the uncertain group there seemed to be a group of female students who were not motivated by patient contact and a group of male and female students who wanted combine work with family. Perhaps this means that if you want to be able to combine work with family in a satisfying way, career choices are much harder to make. Also, it is interesting that female students who went against a traditional gender pattern – being female and less concerned with patient contact – seemed to find it harder to choose a specialty.
A considerable number of students added a good working environment and nice colleagues when asked if something other than the stated motivational factors would affect their specialty preference. This finding is supported by a Swedish study where male and female students described how their reception among colleagues was important when making their career choices [33].
Also, an American study found that the reason for more men choosing surgery could not be explained by the women being deterred from surgery during their clinical rotations but rather that they received more support elsewhere [1].
To sum up, our results suggest that gender segregation is not just a matter of individual choices and gender- dichotomized preference; instead we found that contexts structure choices. First, in contrast to several other Western societies, Swedish men and women have very similar specialty preferences at the time of their gradu- ation. Second, in the male- dominated surgical special- ties both male and female students prioritize family low, whereas for women work-family balance is a major motivational factor to choose family medicine. Third, the importance of social support at the workplace was reflected in the students’ addition of a good working climate as an important factor for specialty preference.
Part-time ideal
Almost half of the medical students who were standing on the doorstep of working-life preferred a part-time practice. In Sweden, 29% of all female physicians work part-time, which can be compared with a majority of the female students in our study who planned for part-time practice. In a similar vein, 17% of the male physicians
work part-time, compared with a good third of the male students who intended to do so [34]. If these students’
preferences stay on and they get their way, the propor- tion of part-time practicing physicians could be almost doubled within a few decades. In Sweden, parents with small children and a full-time job have a legal right to work part-time (75%). Perhaps, medical students believe that this, together with an expected future shortage of doctors mean that they will be able to negotiate their working hours. In a Nordic report on the future supply of physicians, 20% of all Swedish physicians were expected to practice part- time in 2020 [35]. The report made an underestimation, as 23% of all Swedish physicians prac- ticed part-time already in 2009 [34]. This raises a concern.
If a new generation of doctors successfully negotiates part-time practice the shortage of doctors will be even larger than expected. There is however studies indicating that these students will not get what they wish for. Poten- tial medical students in the U.S. also expected medicine to offer the possibility of part-time [1]. This is surprising, as historically the medical profession has been known for its long hours. In most specialties part-time is not a possibi- lity. Structural and cultural barriers are important obsta- cles for part-time work. Despite a new generation of physicians who value work-life balance [22] the American trend over the last few decades moves towards working long weeks, mainly because of structural constraints [1].
American physicians who work part-time report less pay for the same work-related expectations and long-term sac- rifices such as not being promoted and also criticism from colleagues [1]. Negative attitudes in the workplace toward part-time physicians have been described in Scandinavian studies as well [32,36]. As the students in this study seem to value the support from colleagues, this suspicious- ness toward part-timers will be a rude awakening for the Swedish students when they enter the medical profession.
When the students were asked directly how important it was to be able to combine work with family, both men and women rated it higher than career possibilities.
However, when using regression analysis to study the association between combining work with family and ideal work-time it was clear that it was mainly the female students who planned for part-time in order to have time for family responsibilities. This also means that the female students realize that more working hours mean less time for the family. Earlier research showed that female medical students and physicians were more ready than their male peers to compromise career aspi- rations for family life [17,22,32,33]. Thus, even if Sweden has relatively strong parental leave and childcare provi- sions, there are still differences in how male and female future physicians plan their careers. In concert with our results, it has been shown before how Swedish medical students receive gendered advice; men were encouraged
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to stick to what they aspired for and to let family inter- ests come second whereas women were advised to choose a family-friendly specialty [33]. In sum, even if male and female students have similar specialty pre- ferences, it was mainly women and especially those opting for family medicine that planned for work-family balance. However, this did not seem to affect their specialty preference, as there were no gender differences in opting for family medicine and surgical specialties.
Strengths and limitations
The study population covered six classes of medical students and the response rate was high (89%). Seven out of ten motivational factors were useful when meas- uring their link to specialty preference. Some limitations in the current study warrant a discussion. This was a cross-sectional study and therefore one should be cau- tious about causality between motivational factors and specialty preference. Probably, they were both influenced by a general attitude toward work and the social dis- courses associated with the study being conducted at a Swedish university. The results were derived from a single medical school, which means that our findings were not necessarily representative of medical students in general. A majority of the students have however moved to Umea from all parts of Sweden. The partici- pants were last-year students and still had to complete an internship that lasts at least one and a half year before choosing a specialty, which means they had quite some time to change their mind. This means that stu- dents ’ preferences during medical school can, at its best, be used as an indication of what specialty they finally end up in. Using fixed alternatives together with a fixed scale implies a risk of neglecting factors of importance for career choice. Looking at the motivational factors that the students added themselves, we realized that we probably missed some important motives such as work- ing climate and the possibility to choose where to live.
Conclusions
The gender similarities in the medical students’ specialty preferences should be seized by the health care system in order to counteract the horizontal gender segregation in the physician workforce of today. One must acknow- ledge that Swedish medical students do not have dichot- omized motivations for their specialty preference based on gender; instead men and women mainly show simi- larities. There is also a need to discuss gender and the interface between work and family life in medical schools in order to open up for a more equal gender dis- tribution of time spent at the hospital and at home doing unpaid work.
Competing interests
The authors declare they have no competing interests.
Authors ’ contributions
All five authors have made contributions to the study design, acquisition and interpretation of data. TLJ, PV, KH and EEJ was responsible for making the questionnaire. SD performed the statistical analysis to which KH, EEJ and PV made important contributions. SD drafted the manuscript and EEJ and KH made substantial contribution in writing the manuscript. All authors have been involved in revising the manuscript critically for important intellectual content and have read and approved the final manuscript.
Author details
1
